EMERGENCY MEDICAL AUTHORIZATION S-1
The purpose of this form is to authorize the provision of emergency treatment for delegates who
become ill or injured while on official travel for Business Professionals of America. It is
imperative the following information be furnished to Business Professionals of America so that
the delegates will be cared for properly. The authorization does not cover major surgery unless
the medical opinions of two other licensed physicians or dentists, concurring in the necessity for
such surgery, are obtained prior to the performance of such surgery.
I, ________________________ of ________________________________________________
(Name) (Address) (City, State, Zip)
hereby give my consent for (1) the administration of any emergency treatment deemed
necessary by a licensed physician or dentist, (2) the transfer to any hospital reasonably
accessible, and (3) consent to release the medical information provided.
(Parent’s/Guardian’s Signature if delegate is under 18 years old)
Day Phone________________ Evening Phone________________ Cell Number________________
The following information is needed by any hospital or practitioner not having access to the
delegate’s medical history:
ANY ITEMS MARKED “YES” SHOULD BE
Does the delegate have: EXPLAINED BELOW
1. Any Allergies
FOOD ________YES _______NO
MEDICATION ________YES _______NO
OTHER (insect, etc.) ________YES _______NO
2. Any Health, Physical Handicaps or Problems ________YES _______NO
3. Any Respiratory Problems ________YES _______NO
4. Any Diabetes ________YES _______NO
5. Any Epilepsy ________YES _______NO
6. Any Chronic Disease ________YES _______NO
7. Any Emotional or Psychological Problems ________YES _______NO
8. Any Medication Being Taken at Present ________YES _______NO
9. Any Glasses YES/NO, Contact Lenses YES/NO, Hearing Devices YES/NO worn?
If any of the above questions are marked “YES” please explain, and if taking medication please
give name, amount of dosage and time medication is taken.
10. Date of last tetanus booster _______________/_______/__________.
(Month) (Day) (Year)
11. Does delegate have all required immunization shots? ______YES ______NO